<%@include file="../views/header.jsp" %>
<%@include file="../views/mainMenu.jsp" %>
<%@include file="../views/userMenu.jsp" %>
<%@include file="../views/cntColumnOpen.jsp" %>


 
  <form id="form6" name="form6" class="wufoo leftLabel" enctype="multipart/form-data" method="post" action="#public">

<div class="info">
<h2>Wijzig uw gegevens</h2>
<div>Pas hier uw gegevens aan</div>
</div>

<ul>


<li id="fo6li110" class="    ">
<label class="desc" id="title110" for="Field110">
Naam
</label>
<span>
<input id="Field110" name="Field110" type="text" class="field text" value="" size="12"  />
<label for="Field110">Voornaam</label>
</span>
<span>
<input id="Field110" name="Field110" type="text" class="field text" value="" size="12"  />
<label for="Field110">Tussenvoegsel</label>
</span>
<span>
<input id="Field111" name="Field111" type="text" class="field text" value="" size="12"  />
<label for="Field111">Achternaam</label>
</span>
</li>


<li id="fo6li1" class="complex     ">
<label class="desc" id="title1" for="Field1">
Address
</label>
<div>
<span>
<input id="Field1" name="Field1" type="text" class="field text" value=""  size="26"  />
<label for="Field1">Adres / Huisnummer / Toevoeging</label>
</span>
<span>
<input id="Field2" name="Field2" type="text" class="field text" value=""  size="4"  />
</span>
<span>
<input id="Field2" name="Field2" type="text" class="field text" value=""  size="4"  />
</span>
<span class="left">
<input id="Field5" name="Field5" type="text" class="field text addr" value="" maxlength="15"  />
<label for="Field5">Postcode</label>
</span>
<span class="right">
<input id="Field3" name="Field3" type="text" class="field text addr" value=""  />
<label for="Field3">Woonplaats</label>
</span>
<span class="left">
<input id="Field4" name="Field4" type="text" class="field text addr" value=""  />
<label for="Field4">Provincie</label>
</span>
<span class="right">
<select id="Field6" name="Field6" class="field select addr"  >
<option value=""></option>
<option value="Vietnam">Vietnam</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<label for="Field6">Land</label>
</span>
</div>
</li>

<li id="fo6li8" class="section     ">
<h3 id="title8">Section Break</h3>
<div id="instruct8">A description of the section goes here.</div>
</li>


<li id="fo6li113"
class="    ">


<label class="desc" id="title113" for="Field113">
Untitled
</label>

<div>
<textarea id="Field113"
name="Field113"
class="field textarea medium"
rows="10" cols="50"

 ></textarea>

</div>



</li>


<li id="fo6li112" class="    ">
<label class="desc" id="title112" for="Field112">
Select a Choice
</label>
<div class="col">
<input id="radioDefault_112" name="Field112" type="hidden" value="" />
<span>
<input id="Field112_0" name="Field112" type="radio" class="field radio" value="First Choice" tabindex="10"  checked="checked" />
<label class="choice" for="Field112_0" >
First Choice</label>
</span>
<span>
<input id="Field112_1" name="Field112" type="radio" class="field radio" value="Second Choice" tabindex="11" />
<label class="choice" for="Field112_1" >
Second Choice</label>
</span>
<span>
<input id="Field112_2" name="Field112" type="radio" class="field radio" value="Third Choice" tabindex="12" />
<label class="choice" for="Field112_2" >
Third Choice</label>
</span>
</div>
</li>


<li id="fo6li109" class="complex      "  >
<label class="desc" id="title109" for="Field109">
Attach a File
</label>
<div>
<span class="full">
<input id="Field109" name="Field109" type="file" class="field file large" tabindex="13" />
</span>
</div>
</li>



<li id="fo6li7" class="     ">
<label class="desc" id="title7" for="Field7">
Select a Choice
</label>
<div>
<select id="Field7" name="Field7" class="field select medium" tabindex="14" >
<option value="First Choice" selected="selected">
First Choice
</option>
<option value="Second Choice" >
Second Choice
</option>
<option value="Third Choice" >
Third Choice
</option>
</select>
</div>
</li>


<li id="fo6li9" class="    ">
<label class="desc" id="title9" for="Field9">
Untitled
</label>
<div class="col">
<span>
<input id="Field9" name="Field9" type="checkbox" class="field checkbox" value="First Choice" tabindex="15" />
<label class="choice" for="Field9">First Choice</label>
</span>
<span>
<input id="Field10" name="Field10" type="checkbox" class="field checkbox" value="Second Choice" tabindex="16" />
<label class="choice" for="Field10">Second Choice</label>
</span>
<span>
<input id="Field11" name="Field11" type="checkbox" class="field checkbox" value="Third Choice" tabindex="17" />
<label class="choice" for="Field11">Third Choice</label>
</span>
</div>
</li>



<li class="buttons">
<input name="submit" type="submit" class="btn"  value="Wijzigen" />
</li>

<li style="display:none">
<label for="comment">Do Not Fill This Out</label>
<textarea name="comment" id="comment" rows="1" cols="1"></textarea>
</li>
</ul>
</form>


    <div class="fix"></div>
<!--/post-->                      



<br class="fix" />

<%@include file="../views/cntColumnRight.jsp" %>
<%@include file="../views/footer.jsp" %>